February 15, 2023

ToC 101: What Providers Need to Know about Transitions of Care

Every year one in five Medicare beneficiaries experience a readmission to the hospital within 30 days, costing more than $26 billion each year. More than 50% of those individuals did not have any contact with their primary care provider (PCP) after discharge, which may make it more difficult for patients to understand their instructions, follow new care plans, and avoid an exacerbation of their condition.

Primary care plays a central role in improving transitions of care (ToC). The phrase “transitions of care” is exactly as it sounds. It is a process of transferring a patient’s care from one setting or level of care to another; for example, from a hospital visit to their home.  

Patients are extremely vulnerable when they move between different parts of the healthcare system. During transitions of care, PCPs often encounter care gaps that are beyond their control due to factors such as inaccessible patient records, unclear discharge care plans, or limited effort by others to engage the primary care team or the patient and his or her caregivers.  

How can providers successfully handle transitions of care for their patients and help avoid readmissions?

Transitional Care Management (TCM) services are offered during the 30-day post-discharge period to help combat these care gaps. They are covered by Medicare to help patients transition back to the community. TCM visit components include:

Step 1: Interactive Contact

  • Make sure your patient is contacted within two business days of their discharge and has a scheduled office visit as soon as possible, within 14 days

Step 2: Services Provided by PCP

  • During the face-to-face visit make sure to complete medication reconciliation, review the patient's need for follow up on pending diagnostic tests and treatments, and educate the patient, guardian, or caregiver on the care plan  
  • Interact with other healthcare professionals who may assume or re-assume responsibility for the patient's problems
  • Educate the patient, family, guardian, or caregiver  
  • Evaluate for Social Drivers of Health (SDoH) and connect the patient and family with community resources like transportation or medication delivery  
  • Help schedule required community providers and services follow-up

Step 3: Services Provided by Staff Under PCP Supervision

  • Communicate with the patient, agencies and community service providers
  • Educate the patients, guardian, or caregiver to support self-management, independent living, and activities of daily living
  • Assess and support treatment adherence including medication management
  • Identify available community and health resources
  • Help the patient and family access needed care and services

What are the benefits of proper ToC?


  • Provide for dedicated time for the PCP to provide education to the patient about his/her medical condition and what brought him/her to the hospital in the first place
  • Allow time for medication reconciliation, reviewing medications that were either stopped or started in the hospital, as well as medications that had dosage or frequency changes to ensure that patients are taking medications safely and appropriately
  • Coordinate follow up care with specialists as needed for the patient, as well as assist in setting up community resources that are necessary for a full recovery
  • Reduce hospital readmissions


  • Continue to build that relationship and trust that prompts the patient to call the provider when he/she needs medical guidance the most  
  • Provide PCPs financial support through greater CMS reimbursements
  • Post hospital visits drive savings by reducing readmissions


  • Patient is less likely to be readmitted to the hospital.  
  • This will reduce readmission rates and reduce overall costs for the ACO patient population.

Proper transitions of care empower patients while giving their families peace of mind. To continue learning about ToC and earn CME credit, register for the next webinar in our CME Webinar Series on Tuesday, February 28.